Acute myocardial infarction and heart failure result are a common cause of morbidity and mortality for elderly patients in the United States. Numerous studies have documented that ethnic minority populations receive less intensive cardiac care than non-Hispanic whites in a variety of clinical settings. These studies have focused on major procedures such as coronary artery bypass grafting using both large administrative and small clinically detailed databases. Whether these differences are increasing, or decreasing is unclear. The reasons for racial and gender differences are also unclear. Several studies have documented that age, severity of illness, and insurance status can explain part, but not all of the observed differences in treatment. Whether physician, hospital and regional characteristics affect treatment differences remains unknown. In addition, little is known about differences between racial groups in less invasive interventions such as medication use or smoking cessation counseling. The degree to which these treatment differences explain differences in survival is also not known. The aim of this proposal is to further examine racial differences in treatment of acute myocardial infarction and heart failure among elderly patients in the United States. Using multiple national datasets from the Health Care Financing Administration (Medicare) already available to the investigators, we will examine trends in racial differences in treatment and outcome for elderly patients from 1985 through 1997. Detailed clinical data from Medicare and the National Registry of Myocardial Infarction will be used to examine racial differences in the appropriateness of care for acute myocardial infarction (aspirin, beta-blockers, reperfusion, angiotensin converting enzyme inhibitors, smoking cessation counseling and angiography) and heart failure (angiotensin converting enzyme inhibitors, measures of left ventricular function). Several potential causes of treatment differences will be examined by linking patient data to procedure refusal (Cooperative Cardiovascular Project) physician (American Medical Association Physician Master File), hospital (American Hospital Association data) and regional data (Census bureau statistics at the level of zip code). Examining the physician, hospital and regional variation in treatment differences are necessary if systematic strategies are to be implemented to reduce gender and racial disparities in the treatment of elderly patients.